RIGHT FROM THE START

The RFTS Regional Care Coordinator provides follow-up and coordination on all newborn Hearing Screening referrals, offers RFTS care cooordination to all eligible infants. They will also: Complete assessment and PRSI/Alternate Entry, if necessary, to identify barriers to a healthy care outcome. Develop service care plan with client using the RFTS Service Care Plan. Arrange intervention, meeting identified needs. Make home visits and client contact according to policy. Follow a standardized recording system for documenting client care. Reassess and revise service care plan as needed. Update medical provider of mother's progress/change in service care plan as needed. Send required information to Regional Care Coordinator serving the client. Arrange for/participates in interdisciplinary/interagency problem/service care plan meeting for problem clients to determine the appropriate agency to serve as primary case manager and to assign service care plan responsibilities. Coordinates/ Monitors with other program providing care management to infants such as Birth to Three Projects, and or child with Special Health Needs. Referral of client into appropriate case management system at time of closure/ or at risk are determined. At or near care closure, complete Outcome Measures form and forward to RCC.

The RFTS Coordinator will also: Plan with the client for perinatal care/pediatric care. Plan with the client for participation in WIC for nutritional needs, counseling and food supplements. Model and teach problem solving skills. Plan with the mother for receiving a postpardum exam and family planning services. Plan with the client for support system. Plan with the child for receiving well child visits and immunization services.

Primary needs include, but are not limited to, food, shelter, safety, crisis intervention, transportation assistance, and child care. They will also: Advocate for the child in the community. Intervene immediately when mother or child is in unsafe environment. Intervene in times of crisis. (Exception: for incidents of child abuse/neglect. These must be reported by telephone to Child Protective Services, the Child Abuse Hotline, or local DHHR office.

The RFTS Coordinator will also: Establish cooperative agreements and contracts for referral on the local level. Coordinate services for all disciplines. Communicate with medical care providers.Refer very low birth weight, preterm infants' parent to SSI. (if not referred by hospital at birth.) Monitor receipt of services.